A nurse is preparing to give an emergency sedative injection to an agitated client. Which action by the nurse comprises a violation?

Placing a client in restraints without having a healthcare provider’s order.

Administering the medication to a client behind a closed curtain.

Informing a client that the medication being administered is a vitamin.

Enlisting security personnel to assist with restraining the client.

Answer and Explanation

The Correct Answer is A

Choice A rationale

Placing a client in restraints without having a healthcare provider’s order is a violation of patient rights and safety protocols. Restraints should only be used when absolutely necessary and with proper authorization to ensure the safety and well-being of the patient. Unauthorized use of restraints can lead to physical and psychological harm, and it is essential to follow established guidelines and obtain the necessary orders before applying restraints.

Choice B rationale

Administering the medication to a client behind a closed curtain is not a violation. This action ensures the client’s privacy and dignity during the administration of medication. Maintaining privacy is a standard practice in healthcare settings to respect the patient’s confidentiality and comfort.

Choice C rationale

Informing a client that the medication being administered is a vitamin is a violation of ethical and legal standards. It is essential to provide accurate information to the patient about the medication being administered. Misleading the patient can undermine trust and lead to potential harm if the patient has allergies or contraindications to the medication.

Choice D rationale

Enlisting security personnel to assist with restraining the client is not a violation if done appropriately. In situations where the client poses a danger to themselves or others, it may be necessary to involve security personnel to ensure safety. However, this should be done following proper protocols and with the necessary orders in place.

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Correct Answer is B

Explanation

Choice A rationale

Reporting any change in urine color is not a priority intervention for a terminally ill client who is weak, mouth breathing, and refusing anything to eat or drink. The focus should be on comfort measures.

Choice B rationale

Keeping mucous membranes moist is essential for comfort in terminally ill clients who are mouth breathing and refusing fluids. This can be achieved by offering ice chips, sips of water, or using a moist cloth.

Choice C rationale

Recording the client’s daily weight is not a priority in this situation as the client is terminally ill and the focus should be on comfort rather than monitoring weight.

Choice D rationale
Maintaining the client in high Fowler’s position is not necessary unless it helps with breathing. The priority is to keep the client comfortable.

A. Use everyday language when explaining issues. B. Provide a very well-lit meeting space. C. Speak loudly and face the client. D. Underline key words on the written information E. Answer and explanation

Correct Answer is A

Explanation

Choice A rationale

Using everyday language when explaining issues is the most important action. This ensures that the information is easily understood by older adult clients. Complex medical terms and terminology may be confusing or overwhelming for them, so using plain language enhances comprehension and promotes effective learning.

Choice B rationale

Providing a very well-lit meeting space is important for facilitating communication, especially for older adults who may have visual impairments. However, it is not as crucial as using understandable language.

Choice C rationale

Speaking loudly and facing the client is important for ensuring the client can hear and understand the information. However, speaking loudly may be perceived as patronizing or disrespectful. Many older adults may have normal hearing but prefer clear and normal volume speech.

Choice D rationale

Underlining key words on the written information can be a helpful strategy for emphasizing important points, but it is not as critical as using everyday language when explaining concepts orally. Additionally, not all older adults may benefit from written information, as some may have visual impairments or difficulties reading.

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A nurse is preparing to give an emergency sedative injection to an agitated client. Which action by the nurse comprises a violation?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The palliative care nurse receives a consult for a terminally ill client in the intensive care unit. The client is weak, mouth breathing, and refusing anything to eat or drink. Which intervention should the nurse include in the plan of care?

Correct Answer is B

Explanation

When providing health teaching to older adult clients, which action is most important for the nurse to implement?

Correct Answer is A

Explanation

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